Notice Of Voluntary Reopening Own Motion Claim {3501}

Insurer name, address, and phone: Notice of Voluntary Reopening Own Motion Claim Pursuant to ORS 656.278(5) Worker: Mailing date: WCD file no.: Date of Injury: Social Security no.: Insurers claim no.: Your aggravation rights have expired under ORS 656.273. However, you may be eligible for additional disability benefits under ORS 656.278. Your claim has been reopened for: A.Worsened Condition claim submitted after expiration of aggravation rights. ORS 656.278(1)(a). List previously accepted medical condition(s) that has/have worsened. B.Post-Aggravation Rights New or Omitted Medical Condition Claim. ORS 656.278(1)(b). List accepted post-aggravation rights new or omitted medical condition(s) as set forth in the Modified Notice of Acceptance issued under ORS 656.262(6) and OAR 436-060-0140. (Copies of Modified Notice of Acceptance have been issued to claimant, with copies to claimants attorney, if any, and the Workers Compensation Division. See OAR 438-012-0024(1)(a), (2)(a).) C. Pre-1966 Injury Claims. ORS 656.278(1)(c). 1. Pre-1966 Medical Services Claim 2. Pre-1966 Worsened Condition Claim List previously accepted medical condition(s) that has/have worsened. 3. Pre-1966 Post-Aggravation Rights New/Omitted Medical Condition Claim List accepted post-aggravation rights new or omitted medical condition(s) as set forth in the Modified Notice of Acceptance issued under ORS 656.262(6) and OAR 436-060-0140. (Copies of Modified Notice of Acceptance have been issued to claimant, with copies to claimants attorney, if any, and the Workers Compensation Division. See OAR 438-012-0024(1)(a), (2)(a)). NOTICE TO WORKER If a dispute arises out of a voluntary reopening of a claim under ORS 656.278(5), you or your insurer may file a written request for review by the State of Oregon Workers Compensation Board. Send your request to: Own Motion Unit, Workers th Compensation Board, 2601 25 St. SE, Ste. 150, Salem, Oregon 97302-1282. You must send a copy of your request to the insurer or self-insured employer named at the top of this form. Within 14 days after notification from the Workers Compensation Board that a review has been requested, the carrier shall submit to the Workers Compensation Board and to you or your attorney, if any, legible copies of all the evidence that pertains to your compensable condition at the time of the voluntary reopening. The insurer may also submit written arguments at this time, with copies to you or your attorney, if any. Within 21 days of the date the insurer mails these written arguments, you must submit any additional evidence and written argument to the Workers Compensation Board. Authorized representative: (Please type name): Distribution (one copy each to): Worker Workers representative (if any) Workers Compensation Division By: Insurer Signature Date 3501 440-3501 (9/03/DCBS/WCD/WEB) This is an important document. Keep it in a safe place.